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Albacker T, Tash A, Alamri H, Alasnag M, Alkashkari W, Almutairi F, Alqoofi F, Alsaileek A, Aluthman U, Alzahrani G, Balghith M, Makhdom F. Saudi Heart Association/National Heart Center/Saudi Arabian Cardiac Interventional Society/Saudi Society for Cardiac Surgeons/Saudi Cardiac Imaging Group 2023 TAVI Guidelines. J Saudi Heart Assoc 2024; 36:184-231. [PMID: 39234557 PMCID: PMC11373420 DOI: 10.37616/2212-5043.1379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/15/2024] [Accepted: 05/28/2024] [Indexed: 09/06/2024] Open
Abstract
Saudi Arabia has seen a significant improvement in its healthcare system over the past four decades resulting in an increase in life-expectancy. Transcatheter aortic valve implantation (TAVI) has spread widely in Saudi Arabia and has become a routine procedure in many centers. The expanding clinical indications and the availability of the technology have made it possible for many large and intermediate centers all over the country to commence their own TAVI programs. So, the aim of this document is to standardize TAVI practices in different Saudi Arabian centers through reasonable guidelines based on the evaluation and summarization of the best available evidence. The review committee, composed of different experts in several aspects of the management of patient undergoing TAVI, based their recommendations on the reviewed and analyzed evidence and the class and level of recommendations were discussed until a consensus was reached by the panel.
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Affiliation(s)
- Turki Albacker
- Cardiac Sciences Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- King Fahad Cardiac Center, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Adel Tash
- National Heart Center, Saudi Health Council, Saudi Arabia
| | | | - Mirvat Alasnag
- Cardiac Center, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Wail Alkashkari
- King Abdulaziz Medical City - Jeddah and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Fawaz Almutairi
- King Abdulaziz Medical City - Riyadh and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | | | - Ahmed Alsaileek
- King Abdulaziz Medical City - Riyadh and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Uthman Aluthman
- King Faisal Specialist Hospital and Research Centre, Saudi Arabia
| | | | - Mohammed Balghith
- King Abdulaziz Medical City - Riyadh and King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Saudi Arabia
| | - Fahd Makhdom
- Imam Abdul Rahman Bin Faisal University, Saudi Arabia
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2
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Lorente-Ros M, Das S, Malik A, Romeo FJ, Aguilar-Gallardo JS, Fakhoury M, Patel A. In-hospital outcomes of transcatheter aortic valve replacement in patients with chronic and end-stage renal disease: a nationwide database study. BMC Cardiovasc Disord 2024; 24:21. [PMID: 38172786 PMCID: PMC10765730 DOI: 10.1186/s12872-023-03684-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) and end-stage renal disease (ESRD) have been associated with worse outcomes after transcatheter aortic valve replacement (TAVR). With TAVR indications extending to a wider range of patient populations, it is important to understand the current implications of chronic renal insufficiency on clinical outcomes. We aim to determine the impact of CKD and ESRD on in-hospital outcomes after TAVR. METHODS We queried the National Inpatient Sample for TAVR performed between 2016 and 2020 using International Classification of Diseases-10th Revision codes. We compared in-hospital mortality and clinical outcomes between three groups: normal renal function, CKD and ESRD. The association between CKD/ESRD and outcomes was tested with multivariable logistic regression analyses, using normal renal function as baseline. RESULTS In the five-year study period, 279,195 patients underwent TAVR (mean age 78.9 ± 8.5 years, 44.4% female). Of all patients, 67.1% had normal renal function, 29.2% had CKD, and 3.7% had ESRD. There were significant differences in age, sex, and prevalence of comorbidities across groups. In-hospital mortality was 1.3%. Compared to patients with normal renal function, patients with renal insufficiency had higher in-hospital mortality, with the highest risk found in patients with ESRD (adjusted odds ratio: 1.4 [95% confidence interval: 1.2-1.7] for CKD; adjusted odds ratio: 2.4 [95% confidence interval: 1.8-3.3] for ESRD). Patients with CKD or ESRD had a higher risk of cardiogenic shock, need for mechanical circulatory support, and vascular access complications, compared to those with normal renal function. In addition, patients with ESRD had a higher risk of cardiac arrest and periprocedural acute myocardial infarction. The incidence of conversion to open heart surgery was 0.3% and did not differ between groups. Post-procedural infectious and respiratory complications were more common among patients with CKD or ESRD. CONCLUSION Patients with CKD and ESRD are at higher risk of in-hospital mortality, cardiovascular, and non-cardiovascular complications after TAVR. The risk of complications is highest in patients with ESRD and does not result in more frequent conversion to open heart surgery. These results emphasize the importance of individualized patient selection for TAVR and procedural planning among patients with chronic renal insufficiency.
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Affiliation(s)
- Marta Lorente-Ros
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside Hospital, New York, NY, USA.
| | - Subrat Das
- Department of Cardiology, New York Medical College, Westchester Medical Center, Valhalla, NY, USA
| | - Aaqib Malik
- Department of Cardiology, New York Medical College, Westchester Medical Center, Valhalla, NY, USA
| | - Francisco Jose Romeo
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Maya Fakhoury
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Amisha Patel
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside Hospital, New York, NY, USA
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3
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Rajiah PS, Alkadhi H, Van Mieghem NM, Budde RPJ. Utility of Photon Counting CT in Transcatheter Structural Heart Disease Interventions. Semin Roentgenol 2024; 59:32-43. [PMID: 38388095 DOI: 10.1053/j.ro.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 11/19/2023] [Accepted: 11/20/2023] [Indexed: 02/24/2024]
Affiliation(s)
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nicolas M Van Mieghem
- Department of Cardiology, Cardiovascular Institute, Thorax Center, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ricardo P J Budde
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Chamberlin JH, Baruah D, Smith C, McGuire A, Maisuria D, Kabakus IM. Cardiac Computed Tomography Protocols in Structural Heart Disease: A State-of-the-Art Review. Semin Roentgenol 2024; 59:7-19. [PMID: 38388099 DOI: 10.1053/j.ro.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/23/2023] [Accepted: 12/01/2023] [Indexed: 02/24/2024]
Affiliation(s)
- Jordan H Chamberlin
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
| | - Dhiraj Baruah
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC.
| | - Carter Smith
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
| | - Aaron McGuire
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
| | - Dhruw Maisuria
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
| | - Ismail M Kabakus
- Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC
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Kalisz K, Moore A, Chaturvedi A, Rajiah PS. Multimodality Imaging in Planning of Complex TAVR Procedures. Semin Roentgenol 2024; 59:57-66. [PMID: 38388097 DOI: 10.1053/j.ro.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/01/2023] [Accepted: 10/09/2023] [Indexed: 02/24/2024]
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Nabipoorashrafi SA, Gulhane A, Chung C, Chalian H. A Pictorial Review of CT Guidance for Transcatheter Aortic Valve Replacement. Semin Roentgenol 2024; 59:44-56. [PMID: 38388096 DOI: 10.1053/j.ro.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 11/15/2023] [Accepted: 11/18/2023] [Indexed: 02/24/2024]
Affiliation(s)
| | - Avanti Gulhane
- Cardiothoracic Imaging Section, Department of Radiology, University of Washington, Seattle, WA
| | - Christine Chung
- Department of Cardiology, University of Washington, Seattle, WA
| | - Hamid Chalian
- Cardiothoracic Imaging Section, Department of Radiology, University of Washington, Seattle, WA.
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Gallo GS, Caruso C, Iannazzo E, Cannataci C, Gerasia R, Tafaro C, Gentile G, Mamone G, Caruso S, Marrone G, Gandolfo C, Miraglia R. Feasibility of Ultra-Low Volume Contrast-Saline Mixture Injection With Dual-Flow Technique in a Pre-TAVI Computed Tomography Angiography. Heart Lung Circ 2023; 32:525-534. [PMID: 36804708 DOI: 10.1016/j.hlc.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 12/10/2022] [Accepted: 12/16/2022] [Indexed: 02/19/2023]
Abstract
BACKGROUND To explore the feasibility and image quality of ultra-low volume contrast-saline mixture injection with dual-flow injection technique in a computed tomography angiography (CTA) protocol in patients scheduled for transcatheter aortic valve implantation (TAVI). METHODS Forty (40) TAVI candidates underwent investigation with CTA using a third-generation dual-source CT scanner between September and November 2020. Different volumes of a monophasic contrast-saline mixture at an 80:20 ratio were administered at an infusion rate of 3 mL/s in 20 patients (group A). The injected volume was based on patient body mass index (BMI): 50 mL if BMI <29 kg/m2 and 63 mL if BMI >29 kg/m2. The other 20 patients (group B)-the control cases-received a total of 65 mL of contrast medium (CM), in multiphasic injections at different flow rates, followed by 10 mL of saline. The images that were obtained were prospectively evaluated for image quality, vessel attenuation (HU), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and estimated radiation dose. RESULTS Image quality of the aortic root and ilio-femoral vessels was diagnostic in all patients. Vascular attenuation was >200 HU and CNR >3 at any vessel level. CONCLUSIONS Data from this study suggest that a monophasic ultra-low volume contrast-saline mixture injection with a dual-flow technique can provide clear visualisation of the aortic root and ilio-femoral vessels in pre-TAVI CTA, which is comparable with a standard multiphasic volume injection protocol.
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Affiliation(s)
- Giuseppe S Gallo
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy.
| | - Calogero Caruso
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Erica Iannazzo
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | | | - Roberta Gerasia
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Corrado Tafaro
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Giovanni Gentile
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Giuseppe Mamone
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Settimo Caruso
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Gianluca Marrone
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Caterina Gandolfo
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
| | - Roberto Miraglia
- Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IRCCS-ISMETT), Palermo, Italy
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Kaproth-Joslin K, Hobbs S, Rajiah P, Chaturvedi A, Chaturvedi A. Optimizing low contrast volume thoracic CT angiography: From the basics to the advanced. J Clin Imaging Sci 2022; 12:41. [PMID: 36128360 PMCID: PMC9479554 DOI: 10.25259/jcis_51_2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 06/30/2022] [Indexed: 11/04/2022] Open
Abstract
Contrast-enhanced CT angiography (CTA) is a widely used, noninvasive imaging technique for evaluating cardiovascular structures. Contrast-induced nephrotoxicity is a concern in renal disease; however, the true nephrotoxic potential of iodinated contrast media (CM) is unknown. If a renal impaired patient requires CTA, it is important to protect the kidneys from further harm by reducing total iodinated CM volume while still obtaining diagnostic quality imaging. These same reduced volume CM techniques can also be applied to nonrenal impaired patients in times of CM shortage. This educational review discusses several modifications to CTA that can be adapted to both conventional 64-slice and the newer generation CT scanners which enable subsecond acquisition with a reduced CM volume technique. Such modifications include hardware and software adjustments and changes to both the volume and flow rate of administered CM, with the goal to reduce the dose of CM without compromising diagnostic yield.
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Affiliation(s)
| | - Susan Hobbs
- Department of Imaging Sciences, University of Rochester, Rochester, New York, United States
| | - Prabhakar Rajiah
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Apeksha Chaturvedi
- Department of Imaging Sciences, University of Rochester, Rochester, New York, United States
| | - Abhishek Chaturvedi
- Department of Imaging Sciences, University of Rochester, Rochester, New York, United States
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9
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Liang KW, Yu CL, Lin WW, Lee WL. Transcarotid Transcatheter Aortic Valve Replacement in an Octogenarian With Complex Type B Aortic Dissection and Aneurysm: A Case Report. CJC Open 2021; 3:1182-1185. [PMID: 34712942 PMCID: PMC8531222 DOI: 10.1016/j.cjco.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022] Open
Abstract
We report the case of an octogenarian with severe aortic valve stenosis, chronic kidney disease (CKD) and heart failure. Due to advanced CKD, we used a 3-dimensional transesophageal echocardiogram for sizing the device before transcatheter aortic valve replacement (TAVR). Noncontrast computed tomography found complex aortic dissection involving the arch, descending thoracic aorta, and abdominal aorta. TAVR was approached via the right carotid artery using a CoreValve. There was no cerebral vascular event. Renal function was well preserved. Transcarotid TAVR can be performed safely with complex type B aortic dissection. Three-dimensional transesophageal echocardiogram provides an alternative sizing solution in advanced CKD.
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Affiliation(s)
- Kae-Woei Liang
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chu-Leng Yu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Wen Lin
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Life Science, Tunghai University, Taichung, Taiwan.,Department of Medicine, China Medical University, Taichung, Taiwan
| | - Wen-Lieng Lee
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Shroff GR, Bangalore S, Bhave NM, Chang TI, Garcia S, Mathew RO, Rangaswami J, Ternacle J, Thourani VH, Pibarot P. Evaluation and Management of Aortic Stenosis in Chronic Kidney Disease: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e1088-e1114. [PMID: 33980041 DOI: 10.1161/cir.0000000000000979] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aortic stenosis with concomitant chronic kidney disease (CKD) represents a clinical challenge. Aortic stenosis is more prevalent and progresses more rapidly and unpredictably in CKD, and the presence of CKD is associated with worse short-term and long-term outcomes after aortic valve replacement. Because patients with advanced CKD and end-stage kidney disease have been excluded from randomized trials, clinicians need to make complex management decisions in this population that are based on retrospective and observational evidence. This statement summarizes the epidemiological and pathophysiological characteristics of aortic stenosis in the context of CKD, evaluates the nuances and prognostic information provided by noninvasive cardiovascular imaging with echocardiography and advanced imaging techniques, and outlines the special risks in this population. Furthermore, this statement provides a critical review of the existing literature pertaining to clinical outcomes of surgical versus transcatheter aortic valve replacement in this high-risk population to help guide clinical decision making in the choice of aortic valve replacement and specific prosthesis. Finally, this statement provides an approach to the perioperative management of these patients, with special attention to a multidisciplinary heart-kidney collaborative team-based approach.
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Hassanein M, Abdelfattah OM, Saad AM, Isogai T, Gad MM, Ahuja KR, Ahmed T, Shekhar S, Fatica R, Poggio E, Kapadia SR. Short-Term Outcomes of Transcatheter Aortic Valve Replacement in Kidney Transplant Recipients: A Nationwide Representative Study. STRUCTURAL HEART 2021. [DOI: 10.1080/24748706.2020.1845918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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12
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Abd Alamir M, Nazir S, Alani A, Golub I, Gilchrist IC, Aslam F, Dhawan P, Changal K, Ostra C, Soni R, Elzanaty A, Budoff M. Multidetector computed tomography in transcatheter aortic valve replacement: an update on technological developments and clinical applications. Expert Rev Cardiovasc Ther 2020; 18:709-722. [PMID: 33063552 DOI: 10.1080/14779072.2020.1837624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of patients with underlying sever aortic valve stenosis across all spectrum of the disease. CT imaging is so crucial to the pre procedural planning, to incorporate the information from the CT imaging in the decision making intraprocedurally and to predict and identity the post procedural complications.Areas covered: In this article, we review available studies on CT role in TAVR procedure and provide update on the technological developments and clinical applications.Expert opinion: CT imaging, with its high resolution, and in particular its utilization in aortic annular measurements, bicuspid aortic valve assessment, hypoattenuated leaflet thickening and valve in valve therapy proved to be the ideal approach to study the mechanisms of aortic stenosis, detection of high-risk anatomy, more accurate risk stratification and thus to allow a personalized catheter based intervention of the affected patients.
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Affiliation(s)
- Moshrik Abd Alamir
- Department of Cardiology, Stony Brook University Hospital, Health Sciences Tower , Stony Brook, NY, USA
| | - Salik Nazir
- Department of Cardiology, University of Toledo , Toledo, OH, USA
| | - Anas Alani
- Loma Linda University , Loma Linda, CA, USA
| | - Ilana Golub
- Department of Cardiology, Lundquist Institute , Torrance, CA, USA
| | - Ian C Gilchrist
- Department of Cardiology, Stony Brook University Hospital, Health Sciences Tower , Stony Brook, NY, USA
| | - Faisal Aslam
- Department of Cardiology, Stony Brook University Hospital, Health Sciences Tower , Stony Brook, NY, USA
| | - Puneet Dhawan
- David Geffen School of Medicine at UCLA, Department of Surgery, Los Angeles County Harbor-UCLA Medical Center , Torrance, CA, USA
| | - Khalid Changal
- Department of Cardiology, University of Toledo , Toledo, OH, USA
| | - Carson Ostra
- Department of Cardiology, University of Toledo , Toledo, OH, USA
| | - Ronak Soni
- Department of Cardiology, University of Toledo , Toledo, OH, USA
| | - Ahmad Elzanaty
- Department of Cardiology, University of Toledo , Toledo, OH, USA
| | - Matthew Budoff
- Department of Cardiology, Lundquist Institute , Torrance, CA, USA
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Kang EJ. Clinical Applications of Wide-Detector CT Scanners for Cardiothoracic Imaging: An Update. Korean J Radiol 2020; 20:1583-1596. [PMID: 31854147 PMCID: PMC6923215 DOI: 10.3348/kjr.2019.0327] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/23/2019] [Indexed: 12/21/2022] Open
Abstract
Technical developments in multidetector computed tomography (CT) have increased the number of detector rows on the z-axis, and 16-cm wide-area-coverage CT scanners have enabled volumetric scanning of the entire heart. Beyond coronary arterial imaging, such innovations offer several advantages during clinical imaging in the cardiothoracic area. The wide-detector CT scanner markedly reduces the image acquisition time to less than 1 second for coronary CT angiography, thereby decreasing the volume of contrast material and radiation dose required for the examination. It also eliminates stair-step artifacts, allowing robust improvements in myocardial function and perfusion imaging. Additionally, new imaging techniques for the cardiothoracic area, including subtraction imaging and free-breathing scans, have been developed and further improved by using the wide-detector CT scanner. This article investigates the technical developments in wide-detector CT scanners, summarizes their clinical applications in the cardiothoracic area, and provides a review of the recent literature.
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Affiliation(s)
- Eun Ju Kang
- Department of Radiology, College of Medicine, Dong-A University, Busan, Korea.
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14
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Abstract
Computed tomography angiography (CTA) has become a mainstay for the imaging of vascular diseases, because of high accuracy, availability, and rapid turnaround time. High-quality CTA images can now be routinely obtained with high isotropic spatial resolution and temporal resolution. Advances in CTA have focused on improving the image quality, increasing the acquisition speed, eliminating artifacts, and reducing the doses of radiation and iodinated contrast media. Dual-energy computed tomography provides material composition capabilities that can be used for characterizing lesions, optimizing contrast, decreasing artifact, and reducing radiation dose. Deep learning techniques can be used for classification, segmentation, quantification, and image enhancement.
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Affiliation(s)
- Prabhakar Rajiah
- Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55904, USA.
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15
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Suchá D, Kino A, Bogart K, Molvin L, Cheng X, Fearon W, Fischbein M, Fleischmann D. Effect of low contrast medium-dose CTA on device sizing and access vessel assessment for TAVR. Eur J Radiol 2020; 124:108826. [DOI: 10.1016/j.ejrad.2020.108826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/09/2019] [Accepted: 01/06/2020] [Indexed: 01/22/2023]
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16
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Yucel-Finn A, Nicol E, Leipsic JA, Weir-McCall JR. CT in planning transcatheter aortic valve implantation procedures and risk assessment. Clin Radiol 2019; 76:73.e1-73.e19. [PMID: 31883615 DOI: 10.1016/j.crad.2019.11.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 11/13/2019] [Indexed: 12/31/2022]
Abstract
For surgical aortic valve replacement, the Society of Thoracic Surgeons score (STSS) is the reference standard for the prediction of operative risk. In transcatheter aortic valve implantation (TAVI) though, where the procedure itself is minimally invasive, the traditional risk assessment is supplemented by CTA. Through a consistent approach to the acquisition of high-quality images and the standardised reporting of annular measurements and adverse root and vascular features, patients at risk of complications can be identified. In turn, this may allow for a personalised procedural approach and treatment strategies devised to potentially reduce or mitigate this risk. This article provides a systematic and standardised approach to pre-procedural work-up with computed tomography angiography (CTA) and explores the current state of evidence and future areas of development in this rapidly developing field.
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Affiliation(s)
| | - E Nicol
- Royal Brompton Hospital, London, UK
| | - J A Leipsic
- St Paul's Hospital, Vancouver, British Columbia, Canada
| | - J R Weir-McCall
- Royal Papworth Hospital, Cambridge, UK; University of Cambridge School of Clinical Medicine, Cambridge, UK.
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Pulerwitz TC, Khalique OK, Leb J, Hahn RT, Nazif TM, Leon MB, George I, Vahl TP, D'Souza B, Bapat VN, Dumeer S, Kodali SK, Einstein AJ. Optimizing Cardiac CT Protocols for Comprehensive Acquisition Prior to Percutaneous MV and TV Repair/Replacement. JACC Cardiovasc Imaging 2019; 13:836-850. [PMID: 31422136 DOI: 10.1016/j.jcmg.2019.01.041] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 01/14/2019] [Accepted: 01/22/2019] [Indexed: 01/13/2023]
Abstract
Clinical trials of transcatheter mitral valve and tricuspid valve repair and replacement devices have begun in earnest, with the ultimate goal of providing definitive, nonsurgical treatment for the millions of patients with severe, symptomatic regurgitation, many of whom are too high risk or inoperable for a surgical approach. Computed tomography (CT) angiography offers the potential for detailed anatomic assessment in this patient population, but its optimal implementation for patients with mitral and tricuspid disease requires patient-centered protocol specification reflecting the goal of the scan, an understanding of complex anatomy and pathophysiology, and particulars of CT scanner capabilities. In this paper, the need for new interventional approaches to mitral and tricuspid valve disease is discussed, followed by a detailed review of how to perform a high-quality CT angiography examination, taking into consideration scanner- and patient-specific variables when preparing a pre-mitral or tricuspid protocol. The many possible clinical challenges affecting the performance of cardiac and vascular CT angiography for pre-procedure mitral and tricuspid repair/replacement are reviewed and specific tips, trouble-shooting approaches, and recommendations are provided for how to conduct the best-quality study, be it at an experienced imaging center with the most advanced scanner or at a novice center using an earlier generation CT platform.
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Affiliation(s)
- Todd C Pulerwitz
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York; Department of Radiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Omar K Khalique
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York; Department of Radiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Jay Leb
- Department of Radiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Rebecca T Hahn
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Tamim M Nazif
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Martin B Leon
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Isaac George
- Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Torsten P Vahl
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Belinda D'Souza
- Department of Radiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Vinayak N Bapat
- Department of Surgery, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Shifali Dumeer
- Department of Radiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Susheel K Kodali
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York
| | - Andrew J Einstein
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York; Department of Radiology, Columbia University Irving Medical Center/New York-Presbyterian Hospital, New York, New York.
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18
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Baliyan V, Shaqdan K, Hedgire S, Ghoshhajra B. Vascular computed tomography angiography technique and indications. Cardiovasc Diagn Ther 2019; 9:S14-S27. [PMID: 31559151 DOI: 10.21037/cdt.2019.07.04] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Non-invasive cross-sectional imaging techniques play a crucial role in the assessment of the vascular disease processes. Computed tomography angiography (CTA) is an imaging method of choice for a wide range of vascular diseases that span across different vascular territories. A diagnostic quality CTA requires a robust imaging protocol tailored according to the physiologic state and vascular area of interest. This review article is aimed to provide an overview of the technical considerations and clinical applications of CTA.
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Affiliation(s)
- Vinit Baliyan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Khalid Shaqdan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandeep Hedgire
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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19
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Holper EM, Gopal D, Biberstein A, Filardo G, Avila A, Gopal A. Validation of a low-dose contrast 64-slice cardiac computed tomography angiography protocol for aortic valve annulus sizing. Proc (Bayl Univ Med Cent) 2019; 31:414-418. [PMID: 30948969 DOI: 10.1080/08998280.2018.1482515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/18/2018] [Accepted: 05/21/2018] [Indexed: 10/28/2022] Open
Abstract
Cardiac computed tomography angiography (CCTA) is the gold standard for accurately sizing the aortic valve annulus prior to aortic valve replacement. A reduction of contrast volume administered for CCTA, without sacrificing image quality, is desirable. Signal-to-noise ratio represents final CCTA image quality. Consecutive patients referred to CCTA for aortic valve annulus sizing were retrospectively analyzed. Patients were grouped into a low-dose contrast (LDCT) group and traditional dose contrast (TDCT) group. In the LDCT group, contrast dose was <50% of the maximal allowable dose (3.7 × estimated glomerular filtration rate). Guided by a time-density curve, the contrast was administered in a two-stage infusion, and retrospectively gated images were acquired with a 64-multidetector computed tomography scanner. Out of 123 patients (age 80 ± 9 years; 46% female), 65 (52.9%) underwent LDCT and 58 (47.2%) underwent TDCT. Contrast volume was significantly lower in the LDCT group (LDCT 41.2 ± 9.8 vs TDCT 76.2 ± 14.2 mL; P < 0.001). The signal-to-noise ratio of the aortic root was 10.4 ± 4.1 for the LDCT group and 8.4 ± 3.3 for the TDCT group (P = 0.004). Aortic root dimensions could be measured in both LDCT and TDCT groups. In conclusion, LDCT with 64-slice CCTA can effectively size the aortic valve annulus to direct aortic valve replacement while offering reduced contrast exposure.
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Affiliation(s)
- Elizabeth M Holper
- The Heart Hospital Baylor PlanoPlanoTexas.,Baylor Research InstitutePlanoTexas
| | | | | | - Giovanni Filardo
- The Heart Hospital Baylor PlanoPlanoTexas.,Department of Epidemiology, Office of the Chief Quality Officer, Baylor Scott & White HealthDallasTexas
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20
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Blanke P, Weir-McCall JR, Achenbach S, Delgado V, Hausleiter J, Jilaihawi H, Marwan M, Norgaard BL, Piazza N, Schoenhagen P, Leipsic JA. Computed tomography imaging in the context of transcatheter aortic valve implantation (TAVI) / transcatheter aortic valve replacement (TAVR): An expert consensus document of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2019; 13:1-20. [DOI: 10.1016/j.jcct.2018.11.008] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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21
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Blanke P, Weir-McCall JR, Achenbach S, Delgado V, Hausleiter J, Jilaihawi H, Marwan M, Nørgaard BL, Piazza N, Schoenhagen P, Leipsic JA. Computed Tomography Imaging in the Context of Transcatheter Aortic Valve Implantation (TAVI)/Transcatheter Aortic Valve Replacement (TAVR). JACC Cardiovasc Imaging 2019; 12:1-24. [DOI: 10.1016/j.jcmg.2018.12.003] [Citation(s) in RCA: 192] [Impact Index Per Article: 38.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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22
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Mata-Mbemba D, Labani A, El Ghannudi S, Jeung MY, Ohlmann P, Roy C, Ohana M. 320-row CT transcatheter aortic valve replacement planning with a single reduced contrast media bolus injection. PLoS One 2018; 13:e0204145. [PMID: 30212567 PMCID: PMC6136810 DOI: 10.1371/journal.pone.0204145] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 09/03/2018] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To reduce the iodine load required for CT Transcatheter Aortic Valve Replacement (TAVR) planning on a 320-row scanner by acquiring the two CT TAVR steps (ECG-gated aortic root CTA and non-gated aorto-ilio-femoral CTA) within a single contrast media bolus injection. METHODS 50 consecutive patients (82.6±6.9 years; 56% female) were prospectively enrolled and underwent a TAVR planning using a 320-row CT, with ECG-gated aortic root CTA immediately followed by a non-gated aorto-iliac acquisition, all within a single bolus of 40-70mL of Iohexol 350mgI/mL. The Iodine load, image quality, SNR, CNR and radiation dose were compared using a Mann-Whitney test to that of 24 consecutive patients (84.3±4.8 years, 58% female) previously imaged on a 64-row scanner with a conventional two-step protocol. RESULTS Iodine load was reduced by 44%. All examinations were of diagnostic quality, with improvement of the aortic root CTA image quality (4.9±0.3 versus 4.6±0.5, p<0.01) and a non-significant decrease of the aorto-iliac CTA image quality (4.7±0.6 versus 4.9±0.3, p = 0.07). SNR and CNR were significantly improved in the aortic root CTA (14.0±5.3 and 10.4±4.5 versus 10.3±4.2 and 6.8±3.3, p<0.01 for both) and non-significantly higher in the aorto-iliac CTA (16.5±8.0 and 14.1±7.9 versus 14.7±5.5 and 12.5±5.0, p = 0.42 and p = 0.66). Total radiation dose was reduced by 32%. CONCLUSION 320-row CT scanner enables a 44% reduction of iodine load in TAVR planning, while maintaining excellent aorto-ilio-femoral arterial enhancement and lowering radiation dose.
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Affiliation(s)
- Daddy Mata-Mbemba
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aissam Labani
- Department of Diagnostic Imaging, Nouvel Hôpital Civil–Strasbourg University Hospital, Strasbourg, France
| | - Soraya El Ghannudi
- Department of Diagnostic Imaging, Nouvel Hôpital Civil–Strasbourg University Hospital, Strasbourg, France
| | - Mi-Young Jeung
- Department of Diagnostic Imaging, Nouvel Hôpital Civil–Strasbourg University Hospital, Strasbourg, France
| | - Patrick Ohlmann
- Department of Cardiology, Nouvel Hôpital Civil–Strasbourg University Hospital, Strasbourg, France
| | - Catherine Roy
- Department of Diagnostic Imaging, Nouvel Hôpital Civil–Strasbourg University Hospital, Strasbourg, France
| | - Mickaël Ohana
- Department of Diagnostic Imaging, Nouvel Hôpital Civil–Strasbourg University Hospital, Strasbourg, France
- iCube Laboratory, University of Strasbourg, Illkirch, France
- * E-mail:
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23
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Foley TR, Stinis CT. Imaging Evaluation and Interpretation for Vascular Access for Transcatheter Aortic Valve Replacement. Interv Cardiol Clin 2018; 7:285-291. [PMID: 29983141 DOI: 10.1016/j.iccl.2018.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) has emerged as an effective therapy for aortic stenosis in patients who are at intermediate and high surgical risk. Vascular access remains critical to the success of the TAVR procedure. This article reviews the use of imaging in planning and executing TAVR access.
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Affiliation(s)
- T Raymond Foley
- Division of Interventional Cardiology, Scripps Clinic, 9898 Genessee Avenue, La Jolla, CA 92037, USA
| | - Curtiss T Stinis
- Division of Interventional Cardiology, Scripps Clinic, 9898 Genessee Avenue, La Jolla, CA 92037, USA.
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24
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Chaikriangkrai K, Jhun HY, Shantha GPS, Abdulhak AB, Tandon R, Alqasrawi M, Klappa A, Pancholy S, Deshmukh A, Bhama J, Sigurdsson G. Diagnostic Accuracy of Coronary Computed Tomography Before Aortic Valve Replacement: Systematic Review and Meta-Analysis. J Thorac Imaging 2018; 33:207-216. [PMID: 29389809 DOI: 10.1097/rti.0000000000000322] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE In aortic stenosis patients referred for surgical and transcatheter aortic valve replacement (AVR), the evidence of diagnostic accuracy of coronary computed tomography angiography (CCTA) has been limited. The objective of this study was to investigate the diagnostic accuracy of CCTA for significant coronary artery disease (CAD) in patients referred for AVR using invasive coronary angiography (ICA) as the gold standard. MATERIALS AND METHODS We searched databases for all diagnostic studies of CCTA in patients referred for AVR, which reported diagnostic testing characteristics on patient-based analysis required to pool summary sensitivity, specificity, positive-likelihood ratio, and negative-likelihood ratio. Significant CAD in both CCTA and ICA was defined by >50% stenosis in any coronary artery, coronary stent, or bypass graft. RESULTS Thirteen studies evaluated 1498 patients (mean age, 74 y; 47% men; 76% transcatheter AVR). The pooled prevalence of significant stenosis determined by ICA was 43%. Hierarchical summary receiver-operating characteristic analysis demonstrated a summary area under curve of 0.96. The pooled sensitivity, specificity, and positive-likelihood and negative-likelihood ratios of CCTA in identifying significant stenosis determined by ICA were 95%, 79%, 4.48, and 0.06, respectively. In subgroup analysis, the diagnostic profiles of CCTA were comparable between surgical and transcatheter AVR. CONCLUSIONS Despite the higher prevalence of significant CAD in patients with aortic stenosis than with other valvular heart diseases, our meta-analysis has shown that CCTA has a suitable diagnostic accuracy profile as a gatekeeper test for ICA. Our study illustrates a need for further study of the potential role of CCTA in preoperative planning for AVR.
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Affiliation(s)
| | - Hye Yeon Jhun
- Department of Medicine, University of Kansas Medical Center, Kansas City, KS
| | | | - Aref Bin Abdulhak
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Rudhir Tandon
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Musab Alqasrawi
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Anthony Klappa
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Samir Pancholy
- The Wright Center for Graduate Medical Education, Scranton, PA
| | | | - Jay Bhama
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Gardar Sigurdsson
- Heart and Vascular Center, University of Iowa Hospitals and Clinics, Iowa City, IA
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25
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Abstract
Non-invasive imaging of the aorta has undergone considerable advancements in recent times; largely driven by the technological advances in computed tomography (CT) and magnetic resonance imaging (MRI). This review article highlights these recent advancements and discusses the current role of different imaging tools in the management of aortic diseases.
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Affiliation(s)
- Vinit Baliyan
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Verdini
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nandini M Meyersohn
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
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26
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Khalique OK, Pulerwitz TC, Halliburton SS, Kodali SK, Hahn RT, Nazif TM, Vahl TP, George I, Leon MB, D'Souza B, Einstein AJ. Practical considerations for optimizing cardiac computed tomography protocols for comprehensive acquisition prior to transcatheter aortic valve replacement. J Cardiovasc Comput Tomogr 2016; 10:364-74. [PMID: 27475972 DOI: 10.1016/j.jcct.2016.07.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 07/03/2016] [Indexed: 01/07/2023]
Abstract
Transcatheter aortic valve replacement (TAVR) is performed frequently in patients with severe, symptomatic aortic stenosis who are at high risk or inoperable for open surgical aortic valve replacement. Computed tomography angiography (CTA) has become the gold standard imaging modality for pre-TAVR cardiac anatomic and vascular access assessment. Traditionally, cardiac CTA has been most frequently used for assessment of coronary artery stenosis, and scanning protocols have generally been tailored for this purpose. Pre-TAVR CTA has different goals than coronary CTA and the high prevalence of chronic kidney disease in the TAVR patient population creates a particular need to optimize protocols for a reduction in iodinated contrast volume. This document reviews details which allow the physician to tailor CTA examinations to maximize image quality and minimize harm, while factoring in multiple patient and scanner variables which must be considered in customizing a pre-TAVR protocol.
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Affiliation(s)
- Omar K Khalique
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA.
| | - Todd C Pulerwitz
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | | | - Susheel K Kodali
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Rebecca T Hahn
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Tamim M Nazif
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Torsten P Vahl
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Isaac George
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Martin B Leon
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Belinda D'Souza
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
| | - Andrew J Einstein
- Columbia University Medical Center/New York Presbyterian Hospital, New York, NY, USA
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